POS0108 REMISSION OR NOT REMISSION? THAT’S THE QUESTION, BUT WHAT’S THE ANSWER? - ILLUMINATING ON REMISSION IN ORDINARY OUTPATIENT CLINICAL RHEUMATOID ARTHRITIS PATIENTS
Authors: A. Brkic, K. Łosińska, A. H. Pripp, M. Korkosz, G. Haugeberg
Journal: Annals of the Rheumatic Diseases (2022)

Background A recent meta-analysis by Ferreira et al. (2020) has questioned the validity of using Patient Global Assessment (PGA) to define remission in the Boolean remission criteria (4-variable remission, 4vR) [1]. This is because PGA, which presumptively reflects a patient’s perception of disease activity, is influenced by both inflammatory and non-inflammatory mechanisms, thus questioning the validity of PGA-related remission definitions when treating patients to target using anti-inflammatory drugs. Further, the impact of PGA differs in the various definitions and algorithms developed to define remission in rheumatoid arthritis (RA). Objectives This study aims to examine remission rates by applying different definitions of remission in an outpatient cohort of RA patients and illuminate the impact of PGA on Boolean remission. Methods Data were obtained during 2019 from RA patients followed at an outpatient clinic in Southern Norway. The composite disease activity scores simple disease activity index (SDAI), clinical disease activity index (CDAI), and disease activity score with 28 joint count with C-reactive peptide (DAS28(3) and with PGA DAS28(4)), as well as Boolean 4vR and without PGA the 3-variable remission (3vR) were used to define remission. Cut-off remission values for CDAI, SDAI, and DAS28 are ≤2.8, ≤3.2, and ≤2.6, respectively. 4vR is attained when PGA ≤10, C-reactive peptide (CRP) ≤10 mg/L, SJC28 ≤1, and TJC28 ≤1, while 3vR when CRP ≤10 mg/L, TJC28 and SJC28 ≤1 [2]. Remission rates for 4vR were also calculated with the PGA cut-offs of ≤20, 30, 40, 50, 60, 70, 80, 90. Results In Figure 1, proportion rates of remission for DAS28(3), DAS28(4), CDAI, SDAI, 3vR, and 4vR with different PGA cut-offs are presented. The proportion of remission were 73% for DAS28(3), 67% for DAS28(4), 37% for CDAI, 38% for SDAI, 23% for 4vR, 65% for 3vR. When comparing the different remissions proportion rate with various cut-offs of PGA in 4vR, SDAI and CDAI lie between a cut-off of ≤20 and ≤30, while DAS28(3), DAS28(4), and 3vR all lies beyond a cut-off of ≤90. Figure 1. Remission rates using different definitions of remission in an outpatient cohort of 502 rheumatoid arthritis patients Conclusion Our data highlights that there is a great variation in remission rates for the different remission definitions, with DAS28(3) having the highest (73%) and the original Boolean remission the lowest (23%) remission rate. While RA patients in DAS28 remission may still have swollen joints, RA patients with no swollen and tender joints and normal CRP may not achieve Boolean remission because of even a minor elevation of PGA above ten, which may not only reflect inflammatory mechanisms. We question the value of using remission definitions where PGA has a large impact when used in ordinary clinical practice to treat patients to remission. Further studies are warranted to illuminate which remission definitions should be used both in studies and in ordinary clinical practice when treating patients with anti-inflammatory drugs. Is it time for a paradigm shift to focus more on objective than subjective measures reflecting disease status and disease activity when aiming for remission daily clinical practice? References [1]Ferreira RJO, Welsing PMJ, Jacobs JWG, Gossec L, Ndosi M, Machado PM, et al. Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients. Ann Rheum Dis. 2020. [2]Felson DT, Smolen JS, Wells G, Zhang B, van Tuyl LH, Funovits J, et al. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum. 2011;63(3):573-86. Acknowledgements To all patients, nurses, and doctors who contributed to the data collection Disclosure of Interests None declared